Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:

• Patient medical history and physical exam,
• Procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
• Patient education and explanations of risks and benefits.
• Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up
• Prepare referral letters as directed by the physician

Dictation/faxing/phone calls and clerical tasks. Prepare referral letters as directed by the physician, via dictation or summary of the medical record. Ensure that letters are mailed or faxed daily to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached. You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.

Ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete. Comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.

Collect, organize, and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. May also assist in developing and maintaining systems to track patient follow up and compliance.

Attend trainings on subjects such as information technology, legal, HIPAA and regulatory compliance, billing, and coding. Quickly assimilate new knowledge into processes and procedures. Proofread and edit physician’s medical documents for accuracy, spelling, punctuation, and grammar.

Bilingual is helpful. Candidate will be crossed trained to work directly with all physicians along with phone triage.

Job Type: Full-time

Pay: $16.00 - $18.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift

Experience:

• Typing: 1 year (Preferred)
• Medical terminology: 1 year (Preferred)

Work Location: In person